Diagnostic Limitations, Patient Characteristics, and Confounding Factors Impacting Neurotologic Lesion Imaging: A Systematic Review

<b>Background</b>: Neuroimaging protocols for neurotologic disease are often developed without consideration of patient-specific factors such as biological differences, clinical presentation variability, and comorbidities. This lack of tailored design contributes to insufficient detection, delayed diagnosis, and inappropriate treatment. <b>Objectives</b>: To critically examine the literature on diagnostic limitations of neuroimaging for neurotologic lesions and identify gaps in protocol validation, accuracy, and clinical translation. <b>Methods</b>: A systematic review of PubMed and Google Scholar was conducted, focusing on studies published between 2015 and 2025 that evaluated diagnostic imaging outcomes in patients with neurotologic lesions. Eligible studies included prospective cohorts, retrospective analyses, and consensus statements. Outcomes of interest included the sensitivity and specificity of imaging modalities, prevalence of misdiagnosis, and the influence of biological, anatomical, and clinical variability on diagnostic performance. <b>Results</b>: The literature demonstrates that neurotologic disorders are frequently associated with diagnostic challenges, including atypical clinical presentations, overlapping symptoms, and stroke mimics, which complicate image interpretation. Standard magnetic resonance imaging (MRI) protocols often miss subtle or early ischemic changes, resulting in delayed intervention. Few studies stratify outcomes by patient characteristics, and most protocols were developed in generalized populations without comprehensive validation. Evidence on advanced imaging modalities (positron emission tomography (PET), single-photon emission computed tomography (SPECT), high-resolution MRI) remains limited, and large-scale prospective studies addressing diagnostic accuracy gaps are lacking. In summary, a total of 27 studies met inclusion criteria. <b>Conclusions</b>: Current neuroimaging methods are insufficiently validated across diverse patient populations, contributing to the underdiagnosis and mismanagement of neurotologic disease. Improved diagnostic accuracy will require large-scale, prospective research, standardized outcome reporting, and imaging protocols designed to account for patient-specific variability.